Measurement of Anxiety and depression among HIV

ORIGINAL ARTICLE

Measurement of Anxiety and Depression among HIV Patients seen in the Philippine General Hospital using the Hospital Anxiety and Depression Scale – Pilipino Version (HADS-P) Deonne Thaddeus V. Gauiran,1 Kenneth G. Samala,1 Jodor A. Lim2 and Ma. Lourdes Rosanna E. De Guzman3 1 Department of Medicine, Philippine General Hospital, University of the Philippines Manila Section of Infectious Diseases, Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila 3 Department of Psychiatry and Behavioral Sciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila

2

ABSTRACT Background. HIV patients suffer from anxiety and depression but a formal assessment infrequently happens. Objectives. The study aimed to measure the prevalence of anxiety and depression among HIV patients in UPPhilippine General Hospital. Methods. This study involving 417 HIV-positive patients used the Hospital Anxiety and Depression Scale – Pilipino version to identify cases, with stepwise regression analysis for correlation. Results. The prevalence of anxiety, depression, and mixed diagnosis was 10.1% (0.072-0.130), 3.1% (0.014-0.048), and 10.8% (0.078-0.138), respectively. Anxiety was correlated with female sex (OR = 7.82, CI 1.03-59.49), unemployment (OR = 1.76, CI 0.90-3.42), smoking (OR = 1.84, CI 0.89-3.79), homosexuality (OR = 7.64, CI 1.36-42.74), and non-use of protective methods during intercourse (OR = 1.81, CI 0.84-3.93). Depression was correlated with unemployment (OR = 2.79, CI 0.91-8.54) and non-disclosure of status (OR = 3.04, CI 0.79-11.67). Mixed diagnosis was correlated to unemployment (OR = 2.09, CI 1.10-3.96), smoking (OR = 2.14, CI 1.08-4.25), homosexuality (OR = 3.14, CI 0.9210.65), and non-use of protective methods during intercourse (OR = 1.65, CI 0.77-3.53). Conclusions. Lower prevalence of anxiety and depression among HIV patients was found in this study compared with other countries. There is, however, a need to allocate resources for screening mental health problems in HIV patients. Key Words: HIV, anxiety, depression, mental health

Introduction

Corresponding author: Deonne Thaddeus V. Gauiran, MD Department of Medicine Philippine General Hospital University of the Philippines Manila Taft Avenue, Ermita, Manila 1000 Philippines Telephone: +63 908 8150248 Email: [email protected]

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ACTA MEDICA PHILIPPINA

The burden of HIV/AIDS still proves to be a significant challenge. The past years have been witness to the many efforts in decreasing the number of individuals with the said infection through advocacy and education but still 36.7 million (30.8-42.9 million) people are living with HIV all over the world in 2016, raising the total number of cases to 76.1 million (65.2-88.0 million) since the start of the HIV epidemic.1 One million (830,000-1.2 million) individuals succumbed to the said infection in that same year.1 Since 2010, new HIV infections among adults declined worldwide by about 11%.1 Unfortunately, the same cannot be said for the Philippines. Unlike most countries in different parts of the world, the HIV/AIDS epidemic in the Philippines is

VOL. 52 NO. 1 2018

Anxiety and Depression among UP-PGH HIV Patients

rapidly growing.2 Though the Philippines is still considered as a low-HIV-prevalence country, with HIV cases estimated at 51 per 100,000 adults (0.051%), the rise in cases is proceeding at an alarming rate.2 In 2013, one HIV case is diagnosed every two hours, coming from an initial estimate of one new case every three days in 2010, with the total estimate number of people living with HIV at 28,072 by the end of the year.2 Majority of cases are males (82%) and belong to the 20-29 years age group (59%).2 The UP-Philippine General Hospital (UP-PGH), through the STD/AIDS Guidance Intervention Prevention Unit (S.A.G.I.P Unit), which was established in 1997, is one of the major centers that cater to STD/HIV/AIDS patients in Metro Manila. It provides care for inpatient and outpatient cases, as well as inter-hospital and interdepartmental referrals.3 Over the last year, it has seen a nearly five-fold increase in new cases. Many studies have shown that patients living with HIV/AIDS suffer from anxiety and depression, but most of the time; a formal assessment by a trained physician does not happen, precluding its adequate management. Several scales are currently available in assessing the overall psychological well-being of patients, and one of the most commonly used is the Hospital Anxiety and Depression Scale (HADS).4 Early detection of depression should alert the physician taking care of HIV/AIDS patients to promptly refer them to a specialist like a psychiatrist so that a holistic approach in the management of HIV/AIDS is established.

The Hospital and Anxiety Depression Scale

The Hospital Anxiety and Depression Scale (HADS) is a widely used health-related quality of life (HRQoL) tool for measuring psychological distress. It was developed in 1983 by Zigmund and Snaith in order to screen patients for the presence of depression and anxiety.4 It is a 14-item questionnaire which includes seven questions each on anxiety and depression and can be self-administered. Since its introduction, the said scale has been translated into several languages including one in Filipino, which was recently validated by de Guzman in 2013.5

Anxiety and depression among HIV patients

A report released in 2006 projected that HIV/AIDS and depression are the two leading causes of disability by 2030.6 This information has several implications since the two are proved to be interlinked. Several studies have shown that individuals suffering from depression is most likely to exhibit risky sexual behavior and are therefore at greater risk of contracting HIV.7-9 On the other hand, a positive HIV test can trigger anxiety and depression in an individual which in turn can lead to unsafe sexual practices and therefore increases the likelihood of spreading the disease.10-12 Also, studies have shown that people who have depression are less likely to adhere to their treatment – be it for mental illness and/or treatment for HIV/AIDS.13 Therefore, depression proves to VOL. 52 NO. 1 2018

be a significant factor in non-adherence to medications and results in poorer health. A study done in 2003 also cited that a significant number of HIV positive individuals who suffer from depression were not officially diagnosed by a trained physician.14 This intricate interrelationship between the occurrence of anxiety and depression and the overall health seeking behavior of individuals proves to be an issue that needs to be addressed because of its impact on the well-being of individuals living with HIV/AIDS.

Research question

What is the prevalence of anxiety and depression among HIV patients seen in UP-Philippine General Hospital using the Hospital Anxiety and Depression Scale – Pilipino Version (HADS-P)?

Significance of the study

Given the increasing trend of HIV/AIDS prevalence in the country, measures must be done to address the different aspects in the management of patients living with the said illness. Recent years have been witness to the many advances in the treatment of HIV/AIDS, which mainly addresses the physical and biological aspect of its treatment. HIV/AIDS, being an illness that entails a multi-faceted approach in its management requires the physician to not just focus on the physical and biological aspects of the disease but on the mental and psychological aspects as well. Currently, there is no established screening and monitoring program for anxiety and depression among patients of the S.A.G.I.P. Unit of the UP-PGH. The results of this study will emphasize the burden posed by anxiety and depression among HIV patients of the unit. This will hopefully open doors to a formal referral system between the clinic and the Department of Psychiatry of the UP-PGH so that a more holistic approach is achieved in the management of HIV.

Objectives

The study aimed to measure the prevalence of anxiety and depression among HIV patients seen in the UPPhilippine General Hospital using the Hospital Anxiety and Depression Scale – Pilipino version (HADS-P). The study also aimed to assess the impact of the following variables on symptoms of anxiety and depression: a. Demographic (age, sex, and civil status) b. Socio-economic (highest educational attainment, employment status, and monthly household income) c. Behavioral (alcohol, cigarette smoking, use of illicit drugs, sexual preference, and use of protective/barrier methods) d. Psychosocial (extent of disclosure and enrolment in other support groups) e. Health (use of anti-retroviral therapy and latest CD4 count)


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Methods Study design and setting

This was a cross-sectional analytic study, which evaluated the prevalence of anxiety and depression among patients diagnosed with HIV at the S.A.G.I.P. Unit of the University of the Philippines – Philippine General Hospital, a tertiary teaching university hospital and assessed the impact of various variables on symptoms of anxiety and depression. The general workflow of the study is outlined in Appendix A.

Study population

Patients who tested positive for HIV through the S.A.G.I.P. Unit of the UP-PGH were included in the study. Inclusion criteria were being eighteen years or older, who tested positive twice by ELISA tests and confirmed by Western Blot. Patients who did not satisfy these criteria were excluded. Patients who could not understand or speak Filipino were also excluded. Consent could be withdrawn at any time and would not result in any adverse consequences on the part of the participant. Identities of patients were coded to maintain confidentiality. Convenience sampling was used. Patients who consulted at the clinic from June 2014 to August 2014 who satisfied the aforementioned inclusion criteria were included in the study.

Data collection

Data were collected by the investigators and clinical staff of the S.A.G.I.P. Unit using a pre-determined data collection form (Appendix B) after a written informed consent (Appendix C) had been obtained from study participants. A sample size of 417 patients was calculated using 80% power and 0.05 significance level. Logistic regression using binary response variable (y=anxiety and/or depression) on a binary independent variable (x=employment status) detects a change in probability (y=1) from baseline value of 0.575 to 0.425 and corresponds with an odds ratio of 0.546. An adjustment was made since multiple regression of the independent variable of interest on the other independent variables in the logistic regression obtained an R-squared statistic of 0.20. Data on demographic, socio-economic, behavioral, psychosocial, and health variables were collected using the data collection form and a review of medical records. Demographic data (in Filipino) were filled out by each study participant while the socio-economic, behavioral, psychosocial, and health data were filled out by the researchers. Demographic variables included age, sex, and civil status. Socio-economic variables included highest educational attainment, employment status, and monthly household income. Behavioral variables included use of alcohol, cigarette smoking, use of illicit drugs, sexual preference, and use of protective/barrier methods. Psychosocial variables included extent of disclosure and enrolment in other support groups. Health variables included anti-retroviral therapy and latest CD4 count. 42


In this study, symptoms of anxiety and depression were measured using a validated Filipino translation of the selfadministered Hospital Anxiety and Depression Scale, also known as the Hospital Anxiety and Depression Scale-Pilipino Version (HADS-P). The scale is composed of seven items on depression (Items 1 to 7) and seven items on anxiety (Items 8 to 14) and each item contain four (0 to 3) response options. The subscales measure anxiety and depression with a range from 0 to 21, with a higher score denoting greater number of symptoms of either anxiety or depression. Specifically, scores of 0 to 7 in each subscale corresponds to a non-case, scores of 8 to 10 corresponds to a borderline case and scores of 11 to 21 corresponds to a case. Administration of the HADS-P took about two to five minutes.

Analysis

STATA version 12 was used for the statistical analysis. Descriptive statistics of the HADS-P anxiety and depression measures were generated with the aim of assessing the prevalence of anxiety and depression in the study population. Prevalence was calculated using the following formula: Prevalence (%) =

Number of identified cases x 100% Number of tested patients

The descriptive statistics of the demographic, socioeconomic, behavioral, psychosocial, and health variables were also compiled. Continuous variables such as age and CD4 counts were presented as means and standard deviations. Categorical variables such as sex (male vs female), civil status (single vs married/co-habiting), educational attainment (not a college graduate vs college graduate), employment status (unemployed vs unemployed), monthly household income ( 14,000Php Use of alcohol No Yes Cigarette smoking No Yes Use of illicit drugs No Yes Sexual preference Heterosexual Homosexual Use of protective/barrier methods No Yes Extent of disclosure No disclosure Disclosed to another person Enrolment in other support groups No Yes Anti-retroviral therapy Not on ART Ongoing ART CD4 count < 200 ≥ 200

HADS – P Anxiety number of cases (%)

HADS – P Depression number of cases (%)

HADS – P Anxiety or Depression number of cases (%)

21 (9.77) 21 (10.40)

7 (3.26) 6 (2.97)

23 (10.70) 22 (10.89)

40 (9.80) 2 (22.22)

13 (3.19) 0

43 (10.54) 2 (22.22)

35 (9.49) 7 (14.58)

11 (2.98) 2 (4.17)

38 (10.30) 7 (14.58)

14 (11.48) 28 (9.49)

3 (2.46) 10 (3.39)

14 (11.48) 31 (10.51)

18 (13.85) 24 (8.36)

7 (5.38) 6 (2.09)

21 (16.15) 24 (8.36)

24 (10.13) 18 (10.00)

8 (3.38) 5 (2.78)

27 (11.39) 18 (10.00)

20 (9.17) 22 (11.06)

8 (3.67) 5 (2.51)

22 (10.09) 23 (11.56)

29 (8.68) 13 (15.66)

10 (2.99) 3 (3.61)

30 (8.98) 15 (18.07)

41 (10.10) 1 (9.09)

13 (3.20) 0

44 (10.84) 1 (9.09)

2 (2.90) 40 (11.49)

1 (1.45) 12 (3.45)

3 (4.35) 42 (12.07)

11 (15.07) 31 (9.01)

3 (4.11) 10 (2.91)

11 (15.07) 34 (9.88)

6 (14.29) 36 (9.60)

3 (7.14) 10 (2.67)

6 (14.29) 39 (10.40)

37 (9.97) 5 (10.87)

11 (2.96) 2 (4.35)

39 (10.51) 6 (13.04)

6 (10.91) 36 (9.94)

1 (1.82) 12 (3.31)

6 (10.91) 39 (10.77)

16 (10.39) 26 (9.89)

5 (3.25) 8 (3.04)

17 (11.04) 28 (10.65)

3.79), and homosexuality (OR = 7.64, CI 1.36-42.74). Lastly, study participants who did not use any protective methods during sexual intercourse were likely to experience symptoms of anxiety (OR = 1.81, CI 0.84-3.93).

Correlates of depression

The multiple logistic regression analysis identified two significant correlates of depressive symptoms (Table 4). Unemployment was positively correlated with symptoms of depression (OR = 2.79, CI 0.91-8.54). Those who did not disclose their status either with family or friends were more likely to experience depression (OR = 3.04, CI 0.79-11.67). 44


Correlates of mixed diagnosis (anxiety or depression)

The multiple logistic regression analysis identified the following variables as correlates of either anxiety or depression (Table 5). Again, those who were unemployed were noted to have more symptoms of either anxiety or depression (OR = 2.09, CI 1.10-3.96). Smokers who participated in the study also experienced more symptoms of anxiety or depression compared with their counterparts (OR = 2.14, CI 1.084.25). Other significant correlates of symptoms of anxiety or depression were homosexuality (OR = 3.14, CI 0.92-10.65) and non-use of protective methods during sexual intercourse (OR = 1.65, CI 0.77-3.53). VOL. 52 NO. 1 2018


Table 3. Results of the multiple logistic regression (anxiety) Sex (Female) Employment status (Unemployed) Cigarette smoking Sexual preference (Homosexual) Non-user of protective methods

OR (95% CI) 7.82 (1.03 – 59.49) 1.76 (0.90 – 3.42) 1.84 (0.89 – 3.79) 7.64 (1.36 – 42.74) 1.81 (0.84 – 3.93)

p value 0.047 0.097 0.098 0.021 0.130

Table 4. Results of the multiple logistic regression (depression) Employment status Unemployed Extent of disclosure No disclosure

OR (95% CI)

p value

2.79 (0.91 – 8.54)

0.072

3.04 (0.79 – 11.67)

0.106

Table 5. Results of the multiple logistic regression (mixed diagnosis) Employment status (Unemployed) Cigarette smoking Sexual preference (Homosexual) Non-user of protective methods

OR (95% CI) 2.09 (1.10 – 3.96) 2.14 (1.08 – 4.25) 3.14 (0.92 – 10.65) 1.65 (0.77 – 3.53)

p value 0.024 0.030 0.067 0.195

DISCUSSION This study is one of the few researches that measure the prevalence of anxiety and depression among patients with chronic diseases being seen in the outpatient setting. The prevalence of anxiety, depression, and anxiety or depression (10.1%, 3.1%, and 10.8%, respectively) noted in this study were lower than those cited in other studies.12,14-16 It was also not congruent with a study by De Guzman in 2013 involving Filipino patients with chronic diseases, which showed a prevalence of anxiety and depression of 14.3% and 26.9%, respectively.5 However, the said study focused on inpatients, which may have explained the higher prevalence of anxiety and depression. The significant variables that were correlated with anxiety and mixed diagnosis were cigarette smoking, homosexuality, and non-use of protective methods during sexual intercourse. Unemployment was a significant variable correlated in anxiety, depression, and mixed diagnosis. Female sex was a significant variable for anxiety alone while non-disclosure of status to either family or friends was positively correlated to symptoms of depression. The finding of smoking being related to anxiety, depression, and mixed diagnosis was also consistent with a large population study done in Europe in 2008 (The HUNT Study).17 The HUNT Study showed smoking was strongest in co-morbid anxiety and depression, followed by anxiety and only marginal in depression. Also, homosexuality was a very significant factor related to anxiety and this was also similar to the findings of a meta-analysis which showed that gays, lesbians, and bisexuals have a 1.5 times risk of having anxiety and/or depression disorders over a period of 12 months or a lifetime.18 Currently, there are no studies supporting that VOL. 52 NO. 1 2018

non-use of protective barrier during sexual intercourse can increase anxiety and depression symptoms and this may serve as a topic for future researches. The finding of unemployment being a significant factor in patients suffering from anxiety, depression, and mixed diagnosis is in agreement with a study done in 2003 which showed that unemployed patients are 2.53 times more likely to have symptoms of anxiety and or anxiety disorder (95% CI 2.37-2.69).19 Female sex, being a positive correlate of symptoms of anxiety, can be explained by the higher prevalence of this condition among women that was also observed in a report on the gender differences of mental health disorders between males and females in the Philippines. It reported that women are two times more prone to having anxiety disorders which can be explained by their unique reproductive function (ie, onset of menses, labor and pregnancy and perimenopausal experiences) as well as gender role socialization (in a hierarchical social structure, women are assigned many roles, namely; domestic, productive, and community activities which they should carry out all at the same time while men are only assigned with productive roles).19 Wiener et al in 2000, have shown that HIV patients who were able to disclose their status to more people enjoy more social support.20 Several studies have also shown that disclosure of HIV status is associated with lower levels of depression. The result of this study is in agreement with these previous studies.21,22 Our study did not find an association between enrolment in a support group and fewer symptoms of anxiety and depression. This is contrary to a research done in Thailand in 2009, which concluded that participation in a support group was associated with fewer symptoms of depression.23 This may be due to the significantly low number of individuals enrolled in a support group that was noted in this study (11.03%). The wide confidence interval noted in the two variables, namely female sex (CI 1.03-59.49; anxiety) and homosexuality (CI 1.36-42.74; anxiety and 0.92-10.65; mixed diagnosis) can be explained by the few number of females (2%) and considerably more number of homosexuals participating in this study (84%). It should also be noted that the mean CD4 counts of patients is relatively high (307.73 cells/mL), and this is most likely due to the significantly higher number of patients enrolled who are currently on anti-retrovirals. The study has several limitations; firstly, the study participants were drawn only from those patients seen in the UP-PGH SAGIP Unit, therefore the data gathered here are underestimates of the true prevalence of HIV patients suffering from anxiety and depression all over the country. Secondly, since some of the data gathered were based on selfreported information, the measures may not be completely accurate. Lastly, a cross sectional study cannot definitely establish the association between the several factors noted and symptoms of anxiety and depression even if these were significant. ACTA MEDICA PHILIPPINA

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CONCLUSIONS AND RECOMMENDATIONS

3.

The prevalence of symptoms of anxiety, depression, and mixed diagnosis (anxiety or depression) in this study population was 10.1%, 3.1%, and 10.8%, respectively. The incessant increase in the number of new cases of HIV may also imply that more patients will likely suffer from affective disorders, hence the prevalence noted in this study are expected to rise as well. Even if this is the most probable scenario, there are currently no established guidelines in screening and monitoring for anxiety and depression in this vulnerable group. HADS-P, a simple and practical tool, can be used to address this gap in the management of people living with HIV (PLHIV), since this self-administered questionnaire only takes about two to five minutes to complete and can be conveniently used in any clinic. Likewise, screening for affective disorders is an emerging important aspect of managing PLHIV, since the presence of anxiety and depression is linked to low compliance to medications leading to poorer health outcomes. Better working opportunities (eg, less discrimination, equal prospects, etc) should be provided to address unemployment among PLHIV, since it is a significant factor that increases the risk of developing anxiety and depression. Also, since cigarette smoking and non-use of protective methods during intercourse were positively correlated with symptoms of anxiety and mixed diagnosis, advice should be given to patients seen in the clinics regarding the importance of smoking cessation and use of protective barriers during intercourse. Clearly, there is a necessity to address mental health in the context of the over-all well-being of PLHIV so that compliance to treatment is enhanced and their quality of life improved.

4.

Statement of Authorship

All authors have approved the final version submitted.

Author Disclosure

All the authors declared no conflict of interest.

Funding Source

This paper was partially funded by the Philippine General Hospital and the authors.

5. 6. 7. 8. 9. 10.

11. 12.

13.

14. 15. 16. 17. 18. 19. 20. 21. 22.

References 1. 2.

46

UNAIDS Global Report: UNAIDS Fact Sheet [Online]. [cited 2017 Jul]. Available from http://www.unaids.org/en/resources/fact-sheet. Philippine National Aids Council. 2016 Global AIDS Response Progress Reporting: Country Progress Report Philippines [Online]. [cited 2016]. Available from http://www.unaids.org/en/ regionscountries/countries/philippines.


23.

Destura RV, Berba RP, Mendoza MT, et al. Profile of HIV/AIDS patients at the Philippine General Hospital: revisiting 9 Years of clinical experience. Phil J Microbiol Infect Dis. 2003; 32:11-21. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983; 67(6):361-70. De Guzman ML. A validation of the hospital anxiety and depression scale (HADS) in the medically ill. Acta Med Philipp.2013;47(3):53-62. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002-2030. PLoS Med. 2006; 3(11):e442. Gupta R, Dandu M, Packel L, et al. Depression and HIV in Botswana: a population-based study on gender-specific socio-economic and behavioural correlates. PLoS One. 2010; 5(12): e14252. Smit J, Myer L, Middlekoop K, et al. Mental health and sexual behaviours in a South African township: a community-based cross– sectional study. Public Health. 2006; 120(6):534-42. Meade CS, Sikkema KJ. HIV risk behavior among adults with severe mental illness: a systematic review. Clin Psychol Rev. 2005; 25(4):433-57. Boarts JM, Buckley-Fischer BA, Armelie AP, Bogart LM, Delahanty DL. The impact of HIV diagnosis-related vs. non-diagnosis related trauma on PTSD, depression, medication adherence, and HIV disease markers. J Evid Based Soc Work. 2009; 6(1):4-16. Hand GA, Phillips KD, Dudgeon WD. Perceived stress in HIVinfected individuals: Physiological and psychological correlates. AIDS Care. 2006; 18(8):1011-7. Pappin, M, Wouters E, Booysen FL. Anxiety and depression amongst patients enrolled in a public sector antiretroviral treatment programme in South Africa: a cross-sectional study. BMC Public Health. 2012; 12:244-52. Horberg MA, Silverberg MJ, Hurley LB, et al. Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIV-infected patients. J Acquir Immune Defic Syndr. 2008; 47(3):384-90. Asch SM, Kilbourne AM, Gifford AL, et al. Underdiagnosis of depression in HIV: who are we missing. J Gen Intern Med. 2003; 18(6):450-60. Shacham E, Morgan J, Önen NF, Taniguchi T, Overton ET. Screening anxiety in the HIV clinic. AIDS Behav. 2012; 16(8):2407-13. Reyes MVT, Reyes B. Engendering Philippine mental health. Speech presented at; 2004; Mandaluyong City Philippines. Mykletun A, Overland S, Aaro LF, Liabo HM, Stewart R. Smoking in relation to anxiety and depression: evidence from a large population survey: The HUNT Study. Eur Psychiatry. 2008; 23(2):77-84. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008; 8:70-86. Comino EJ Harris E, Chey T, et al. Relationship between mental health disorders and unemployment in Australian adults. Aust N Z J Psychiatry. 2003; 37(2):230-5. Wiener LS, Battles HB, Heilman N. Public disclosure of a child’s HIV infection: impact on children and families. AIDS Patient Care STDS. 2000; 14(9):485-97.   Hays RB, McKusick L, Pollack L, Hilliard R, Hoff C, Coates TJ. Disclosing HIV seropositivity to significant others. AIDS. 1993; 7(3):425-31.   Armistead L, Morse E, Forehand R, Morse P, Clark L. AfricanAmerican women and self-disclosure of HIV infection: rates, predictors, and relationship to depressive symptomatology. AIDS Behav. 1999;3(3):195-204. Li L, Lee SL, Thammawijaya P, Jiraphongsa C, Rotheram-Borus MJ. Stigma, social support, and depression among people living with HIV in Thailand. AIDS Care. 2009; 21(8):1007-13.

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AppendiCES Appendix A. Workflow Subjects are recruited at the S.A.G.I.P. Unit of the UP-PGH

Study explained Written consent obtained

Filling up of Case Report Form by subject and investigator

CASE of Anxiety / Depression

Self-administration of HADS-P

Referral to Psychiatry

NOT a CASE of Anxiety / Depression Continuation of care at S.A.G.I.P. Unit

Appendix B. Data Collection Form For study personnel use only ID Code: __________ Date of recruitment: __________ Part I: Demographic, Socioeconomic, Behavorial, Psychosocial and Health Direksyon: Punan ang mga patlang ng mga kasagutan sa mga tanong bilang 1.2 hanggang 1.12. Lagyanng X (ekis) ang mga pagpipilian na tugma sa iyon gsagot. Walang ibang tao ang makakaalam ng mga kasagutan kundi ang mga nagsasagawa ng pagaaral. Maraming salamat. DEMOGRAPHICS (to be kept in a separate sheet with the code. No identifying data other than the code will be placed on all clinical questionnaires and results forms) 1.1 “Code” # (huwag sagutan): __________ 1.2. Edad: __________ 1.3. Lugar ng kapanganakan: __________ 1.4. Nasyonalidad: __________ 1.5. Kasarian: [ ] Male [ ] Female 1.6. Tirahan sa Metro Manila (kung mayroon): ________________________________________ 1.7. Probinsya (kung mayroon): ________________________________________ 1.8. Katayuan: [ ]“Single” [ ] Kasal/May “ka-live in” 1.9. Nakatapos ng kolehiyo? [ ]Oo [ ] Hindi 1.10. May trabaho?: [ ] Wala [ ] Mayroon, 1.11. Kung mayroong trabaho, ano ito? __________ 1.12. Buwanang kita: [ ]